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Polk County Gun Club

 Adult Hold Harmless Agreement
Release and Information Record

INDEMNIFICATION, HOLD HARMLESS, DEFENSE, WAIVER, RELEASE AND ASSUMPTION OF RISK AGREEMENT

           In consideration of being permitted entry to and/or use of “Premises” of Polk County Gun Club for whatever purpose, including, but not limited to, use of firearms and/or other weapons, including, but not limited to, crossbows and longbows) by him/her and/or another, and with full knowledge that firearms and/or other weapons are used and discharged on Club Premises, I, (“Undersigned”) agrees to the following:

           Undersigned agrees to indemnify, hold harmless, and defend Club from any and all fault, liabilities, costs, expenses, claims, demands, and/or lawsuits arising out of, related to, or in any way connected with, any and all actual or alleged acts or omissions of Undersigned in the course of Undersigned’s presence on and/or use of Club’s range, buildings, facilities, and land (together comprising “Premises”) including, but not limited to, Undersigned’s use of firearms and/or other weapons.

           Undersigned further waives for himself/herself and for his/her heirs, next of kin, assignees, personal representatives, administrators, and executors any and all rights and claims for damages, loss, costs, demands, and any other actions or claims whatsoever, which he/she may have or which may arise against Club (including, but not limited to, damage to Undersigned’s property and/or any and all illnesses, injuries, including mental or emotional distress or anguish, and other damages, including death, suffered by Undersigned) which may in any  way whatsoever arise out of, be related to, or be connected with use of firearms and/or other weapons on Club Premises by Undersigned and/or another.

           Club shall not be liable for, and Undersigned, on behalf of himself/herself and on behalf of his/her heirs, next of kin, assignees, personal representatives, administrators, and executors, expressly releases Club and Club’s members, employees, and/or agents from any and all such claims and liabilities including, but not limited to, claims of actual or alleged negligence on the part of Club, its members, employees, and/or agents.

(Over)

           Undersigned acknowledges and agrees that use of firearms and/or other weapons is an inherently dangerous activity. Undersigned expressly assumes the risk of being on Club Premises where firearms and/or other weapons are used; and Undersigned further expressly assumes the risk of discharging firearms and/or use of any weapons by whomever and the firing of live ammunition and/or use of any weapons by himself/herself and/or another.

           Undersigned expressly agrees that this agreement by him/her is intended to be as broad and inclusive as permitted by law and that if any provision of this agreement is held invalid or otherwise unenforceable, the enforceability of the remaining provisions shall not be impaired. No remedy conferred by any of the specific provisions of this agreement is intended to be exclusive of any other remedy, and each and every remedy shall be cumulative and shall be in addition to every other remedy now or hereafter existing at law or in equity or by statute or otherwise. The election of any one or more remedy hereunder by Club shall not constitute any waiver of Club’s right to pursue other available remedies. This agreement binds Undersigned and his/her heirs, next of kin, assignees, personal representatives, administrators, and executors.

           Undersigned acknowledges and agrees that Undersigned has read this agreement and he/she understands its terms and is executing this agreement voluntarily. Undersigned also acknowledges and agrees that he/she has read, understands, and will at all times abide by all range rules and procedures and any other rules and procedures stated by Club.

Date: May 20, 2026

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
Check One:
Member
Guest
If you are a Guest, please designate your purpose for visiting:*
Skeet Match
Trap Match
ASI Match/Practice
Long Range Handgun
GSM-CMP
Bench Rest
High Power
F Class
General Shooting
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Check One:
Member
Guest
If you are a Guest, please designate your purpose for visiting:*
Skeet Match
Trap Match
ASI Match/Practice
Long Range Handgun
GSM-CMP
Bench Rest
High Power
F Class
General Shooting
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Check One:
Member
Guest
If you are a Guest, please designate your purpose for visiting:*
Skeet Match
Trap Match
ASI Match/Practice
Long Range Handgun
GSM-CMP
Bench Rest
High Power
F Class
General Shooting
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Check One:
Member
Guest
If you are a Guest, please designate your purpose for visiting:*
Skeet Match
Trap Match
ASI Match/Practice
Long Range Handgun
GSM-CMP
Bench Rest
High Power
F Class
General Shooting
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Check One:
Member
Guest
If you are a Guest, please designate your purpose for visiting:*
Skeet Match
Trap Match
ASI Match/Practice
Long Range Handgun
GSM-CMP
Bench Rest
High Power
F Class
General Shooting
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Check One:
Member
Guest
If you are a Guest, please designate your purpose for visiting:*
Skeet Match
Trap Match
ASI Match/Practice
Long Range Handgun
GSM-CMP
Bench Rest
High Power
F Class
General Shooting
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Check One:
Member
Guest
If you are a Guest, please designate your purpose for visiting:*
Skeet Match
Trap Match
ASI Match/Practice
Long Range Handgun
GSM-CMP
Bench Rest
High Power
F Class
General Shooting
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Check One:
Member
Guest
If you are a Guest, please designate your purpose for visiting:*
Skeet Match
Trap Match
ASI Match/Practice
Long Range Handgun
GSM-CMP
Bench Rest
High Power
F Class
General Shooting
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Check One:
Member
Guest
If you are a Guest, please designate your purpose for visiting:*
Skeet Match
Trap Match
ASI Match/Practice
Long Range Handgun
GSM-CMP
Bench Rest
High Power
F Class
General Shooting
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Check One:
Member
Guest
If you are a Guest, please designate your purpose for visiting:*
Skeet Match
Trap Match
ASI Match/Practice
Long Range Handgun
GSM-CMP
Bench Rest
High Power
F Class
General Shooting
Parent or Guardian's Email Address
Email
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Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
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Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
Check One:
Member
Guest
If you are a Guest, please designate your purpose for visiting:*
Skeet Match
Trap Match
ASI Match/Practice
Long Range Handgun
GSM-CMP
Bench Rest
High Power
F Class
General Shooting
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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